Apico Implantectomy

5 years ago this patient had multiple maxillary anterior implants.  When I saw her for consultation I thought she was a lawn dart victim.  I checked out #7 but findings were equivocal, the tooth tested vital. it was percussion sensitive but so was #6.  We decided to monitor.  I saw her a year later in 2005, similar symptoms, pulp still vital, but it wasn't as sensitive as a year earlier.  We decided to continue to monitor.  Here gingival tissues during this period were inflamed and she was being passed around from periodontist to periodontist and no one wanted to treat her except the original treating periodontist, but she didn't want to have him treat her (small wonder). She was extremely frustrated.  By 2007 she found a periodontist who did some grafting, her dentist placed some provisionals and she looked a lot better......only one problem she developed a fistula that traced to the #9 implant.  With all the goofing around with the #9 implant the internal threads had been stripped, the cover screw was presumed loose and the consensus opinion was that the internal implant space was communicating and contaminated.  Some suggested that I do an apico on it (only upside down and place MTA in the screw hole space and "put it to sleep".  It wasn't part of the restorative plan because of esthetics.  An implant supported bridge was the new final restorative plan.  I didn't think it would be a good thing to do and suggested that the new periodontist trephine it out and graft the area.  The compromise plan was for the periodontist to do the surgery and drill the coronal part of the implant down deeper eliminating the space area.  I thought that was a good plan and it was done.  A year later the area had healed, but her biting discomfort and sensitivity was isolated to #7.  I finally decided to treat it a year ago to rule out endo.  Of course she still has the same pain one year later. She had another graft performed about 3 months ago.  Tooth #7 is moderately percussion sensitive with normal probing depths.  

This woman is tired of being sliced and diced. Check out all the attached chronologic photos and radiographs.  Clearly the implant in the #8 site is probably close to the apex of #7. 

What would you do? 

An apicoectomy on the maxillary lateral that had its apex into the max central implant replacement.  I couldn’t apically resect the root too much away from the implant without severely shortening it, but I presume we got the root tip cut back enough from the implant to allow good debridement and clotting.  I’ll take another CT when I take the sutures out next week. Reverse-filled the root end with MTA polished and debrided the implant surface with Metronidizole gel where the root tip was in contact.